Systemic steroids and autoimmune conditions pt 2

Question 1

Symptoms of systemic lupus erythematosus

Answer 1

Fatigue, depression, anorexia, weight loss, muscle pain, malar rash (butterfly rash), arthritis symptoms, photosensitivity

Question 2

What contributes to morbidity and mortality of SLE?

Answer 2

Renal, hematologic, and neurologic manifestations
Lupus nephritis (kidney disease) develops in over 50% of patients with SLE

Question 3

Chronic therapy options for SLE?

Answer 3

Limit steroids, may use NSAIDs at anti inflammatory doses

Use hydroxychloroquine, cyclophosphamide, azathioprine, mycophenolate, mofetil, and cyclosporine

(These drugs are discussed in other chapters, only hydroxychloroquine has an FDA indication for SLE)

Takes up to 6 months to see maximal benefit

Question 4

Belimumab brand, dose, warnings

Answer 4

Benlysta
10 mg/kg every 2 weeks for 3 doses then every 4 weeks therafter; infuse over 1 hour
SC 200 mg SC weekly
Stable in NS only
Warnings: infection risk, dont give with other biologic DMARDs or other live vaccines

Question 5

What is multiple sclerosis?

Answer 5

Chronic, progressive autoimmune disease where the patient’s immune system attacks the myelin sheath (the fatty substance that surrounds and insulates the nerve fibers of the brain and spinal cord axons)

Question 6

What is the goal of treatment of MS?

Answer 6

Prevention of disease progression, what is lost in neuronal function cannot be regained

Question 7

What drug classes are mainstay of treatment for patients with relapsing forms of MS?

Answer 7

Interferon beta formulations (Betaseron, Avonex, Rebif, Extavia, Plegridy) and glatiramer acetate (Copaxone, Glatopa) - parenteral drugs

Question 8

Which interferon beta formulation has SC dosing every 14 days?

Answer 8

Plegridy

PEGylated interferon beta

Question 9

Oral options for MS? (oral immune modulators)

Answer 9

Tecfidera (dimethyl fumarate)
Gilenya (fingolimod)
Aubagio (teriflunomide)

Question 10

Glatiramer acetate brand, dose, dose form, side effects

Answer 10

Copaxone, Glatopa
Prefilled syringes
20 mg SC daily or 40 mg SC 3x weekly (at least 48 hours apart)

Side effects: injection site reactions, infection, pain, flushing, diaphoresis, dyspnea

Preferred in pregnancy!

2 dif doses - 20 mg daily or 40 mg MWF

Question 11

Interferon beta-1a brand, dose forms, dose

Answer 11

Avonex, Avonex pen
Powder or pre-filled syringe/pen
30 mcg IM weekly OR 22 mcg or 44 mcg SC MWF

Question 12

Interferon beta-1b brand, dose forms, dose

Answer 12

Betaseron, Extavia
Powder or auto-injector
0.25 mg every other day

Question 13

Peginterferon beta-1a brand, dose forms, dose

Answer 13

Plegridy, Plegridy Starter Pack
Pre-filled syringe and pen
63 mcg on day 1, 94 mcg on day 15, 125 mcg every 14 days starting day 29

Question 14

Warnings, side effects, notes for interferon beta products

Answer 14

Warnings: psychiatric disorders (depression, suicide)
injection site necrosis
increased LFTs
Thyroid dysfunction (hyper or hypo)

Side effects: flu-like symptoms

Notes: refrigerate all except Betaseron and Extavia (room temp)
If refrigerated, let stand at room temp prior to injection
Do not expel small air bubble in pre-filled syringes due to loss of dose

Question 15

Oral immune modulators warnings, side effects, notes (just underlined stuff)

Teriflunomide
Fingolimod
Dimethyl fumarate

Answer 15

Teriflunomide (aubagio): contraindicated in pregnancy

Fingolimod (Gilenya): can cause bradycardia, monitor for at least 6 hours after 1st dose. ECG required at baseline, contraindicated in most patients w history of CV or stroke. Can cause macular edema, monitor with eye exams
Monitor CBC (myelosuppression) and LFTs (hepatotoxicity)

Dimethyl fumarate (Teclidera) Do not crush, chew, or sprinkle capsule contents on food

Question 16

Drugs for Raynaud’s phenomenon

Answer 16

This is where you have vasospasm in extremities, usually fingers and toes
Extremities turn white and then blue then painful swelling
Nifedipine used for prevention but other CCBs can be used
Also use vasodilating agents: iloprost, topical nitroglycerin, and the phosphodiesterase-5 inhibitors

Question 17

Treatment of Celiacs disease

Answer 17

Avoid all gluten obviously but this includes medications
Package inserts contain info on excipient components, look for key word “starch” (corn, potato, tapioca, OR wheat)
If it lists starch alone, manufacturer must be consulted to find out if the starch is wheat

Question 18

What is Sjrogen’s syndrome? Treatment options?

Answer 18

Autoimmune disease mostly characterized by severe dry eyes and dry mouth, but can be associated with other symtpoms like thyroiditis, Raynaud’s, neuropathy, and lymphadenopathy

Dry eyes try artificial tear drops, if not can use Restasis (cyclosporine emulsion eye drops) or lifitegrast (Xiidra)

Dry mouth use lozenges, or can use muscarinic agonists (pilocarpine)

Question 19

What is psoriasis?

Answer 19

Autoimmune disease that appears on the skin
Most often appears as plaque psoriasis, which appears as raised, red patches covered with a silvery white buildup of dead skin cells on any part of the body

Question 20

Drug treatment options of psoriasis

Answer 20

Topical treatments (steroids, coal tar products (messy))

Systemic: tablets (Otezla, or apremilast; Soriatane, or acitreten - use in severe cases only)

IL antagonists: monoclonal antibodies (Siliq, Tremfya, Stelara)

Question 21

Notes, warnings for IL receptor antagonists

Answer 21

Subcutaneous injections
Can result in serious infections, so must screen for latent TB before starting and treat if positive and also avoid live vaccines
May cause diarrhea